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Van Allen v. Colvin

United States District Court, D. Connecticut

September 29, 2016



          Dominic J. Squatrito United States District Judge.

         This is an administrative appeal following the denial of an application filed by the plaintiff, Lance Alex Van Allen (“Van Allen”), for supplemental security income (“SSI”).[1] It is brought pursuant to 42 U.S.C. §§ 405 (g) and 1383 (c)(3).

         Van Allen now moves for an order reversing the decision of the Commissioner of the Social Security Administration (“Commissioner”). In the alternative, Van Allen seeks an order remanding his case for a rehearing. The Commissioner, in turn, has moved for an order affirming her decision.

         The issues presented are whether: (1) the ALJ erred in finding that Van Allen's alcohol abuse was a material factor to a finding of disability; (2) the ALJ properly applied the treating physician rule; and (3) the ALJ's residual functional capacity (“RFC”) determination is supported by substantial evidence. For the following reasons, Van Allen's motion to reverse is denied, and the Commissioner's motion for an order affirming her decision is granted.


         An examination of the record discloses the following: On July 26, 2011, Van Allen filed an application for SSI for an alleged disability that commenced on January 1, 2001. On November 3, 2011, a disability adjudicator in the Social Security Administration denied his application for SSI and thereafter denied his request for reconsideration.

         On August 29, 2013, Van Allen appeared with counsel for a hearing before an ALJ. On October 25, 2013, the ALJ issued a decision denying benefits. On December 10, 2014, the Appeals Council denied Van Allen's request for review of that decision thereby making the ALJ's decision the final decision of the Commissioner. This appeal followed.

         Van Allen, who was born on October 2, 1968, has an eleventh grade education. He has no past relevant work history.

         Medical Evidence

         A. Physical Impairment

         On November 14, 2007, Dr. Cary Freston issued a consultative examination report concerning Van Allen on behalf of Connecticut Disability Determination Services. Van Allen had reported having “no use of [his] right arm” and a loss of vision in his right eye. (Doc. # 10-8, at 114, p. 407)[2]. The results of a physical examination indicated “[u]nlimited range of motion in both shoulders” and “[f]ull flexion and extension right elbow.” (Id. at 116, p. 409). The report also notes that “[r]ight elbow supination[3] is limited by approximately 15 to 25% of range, but full pronation[4] is noted.” (Id.). The report additionally noted “a mild grade clubbing”[5] of the left hand ring finger. (Id.). With regard to Van Allen's right eye, the report indicated that “there is vision present as patient blinked to oncoming object in isolated right eye vision, and he can identify close objects, but with distant vision he describes this as being quite problematic.” (Id.).

         On April 21, 2009, Van Allen was examined by Dr. Gursharan Dhaliwal. The notes of that visit state the following:

PT [patient] presented c/o [complaining of] lower back pain secondary to lifting a heavy log. PT was vague in his time line. Not describing his pain and then stating that the pain was in his shoulders. . . . When I walked into the room [he] was completely bent over fixing [his] shoe. He had told the nurse that he could not bend over at all. When questioned about this he said “do you think I'm a li[a]r.”

(Doc. # 10-11, at 64, p. 1078). Dr. Dhaliwal found no abnormalities in Van Allen's cervical spine, thoracic spine, or lumbar spine.

         Van Allen visited the Charter Oak Health Center (“Charter Oak”) on July 7, 2011. In the report of that visit, he is described as a “42 yo male with chronic pain after being ‘buried alive' [and] also with retinal detachment [in his] left eye.” (Doc. # 10-10, at 2, p. 754). A physical examination performed that day was unremarkable. A July 15, 2011 visit to Charter Oak also resulted in an unremarkable physical examination. The report of that visit lists as a chronic problem, “Diabetes mellitus without mention of complication.” (Id. at 4, p. 756).

         On August 10, 2011, Van Allen visited Charter Oak complaining of knee and back pain. A physical examination, performed by APRN Sheldon Hollins[6], indicated no thoracic or lumbar spine tenderness and full range of motion in both knees. A follow-up lumbar spine x-ray disclosed “bilateral spondylolysis . . . but no significant spondylolisthesis is evident.”[7] (Id. at 30, p. 782). A thoracic spine x-ray was negative.

         Van Allen visited Dr. Dhaliwal again on November 5, 2012, complaining of back and knee pain. Dr. Dhaliwal's treatment notes reflect that Van Allen informed the doctor that “he loads trailers with tires and feels a lot of lower back pain when he stops working.” (Doc. # 10-11, at 65, p. 1079). Van Allen also informed the doctor that he had “a dirt bike accident years ago and it gives out intermittently.” (Id.). Examination of his back was normal except for lower back muscle spasms. His knees had normal movement and no tenderness on palpation or ambulation.

         On June 18, 2013, x-rays were taken of Van Allen's spine and left knee. The findings concerning his spine indicated “minimal anterolisthesis”[8] of L5-S1[9] and “minimal degenerative spondylosis”[10] at ¶ 3-L4 and L5-S1. (Id. at 73, p. 1087). The x-ray of the left knee was normal.

         On July 13, 2013, Van Allen had an MRI taken of his lumbar spine, as well as one of his right shoulder. With regard to the lumbar spine, the MRI indicated a disc extrusion and a disc protrusion[11] at ¶ 5-S1 resuling in “mild to moderate bilateral neural foraminal encroachment[12] at ¶ 5-S1.” (Id. at 75, p. 1089).That MRI also indicated hypoplasia[13] of L5, noted a “small dorsal annular fissure[14]. . . at ¶ 4-5, ” and reaffirmed the previously detected spondylolysis. (Id.). The MRI of Van Allen's right shoulder indicated “[m]oderate hypertrophic acromioclavicular osteoarthritis.”[15] (Id. at 76, p. 1090).

         In a Vision Medical Source Statement dated July 15, 2013, Dr. Susan Janik reported that Van Allen had “no light perception in [his] left eye, ” effectively making him “monocular.” (Id. at 52, 53, pp. 1066, 1067). In her Statement, Dr. Janik opined that Van Allen could frequently lift and carry less than 10 pounds, occasionally lift and carry up to 10 pounds, frequently bend, and occasionally squat.

         APRN Katherine Dugan completed a form entitled “Physical Medical Source Statement” concerning Van Allen dated August 26, 2013. In that statement, Nurse Dugan listed diagnoses of “shoulder pain, arthritis, back pain worsening.” (Id. at 87, p. 1101). She identified the “clinical findings and objective signs” of Van Allen's diagnoses as “decreased ROM [range of motion] of shoulder, tenderness to palpation of lower back, decreased fine motor of hand.” (Id.). She then offered her opinions that due to his shoulder and back pain Van Allen could sit and stand/walk for less than two hours in an 8-hour working day, could never bend, squat, climb stairs or ladders, was incapable of tolerating even low stress in a work setting, and would likely be absent from work more than four days per month as a result of his impairments. The form completed by Nurse Dugan included the following advisement: “Attach relevant treatment notes, radiologist reports, laboratory and test results as appropriate.” (Id.) (emphasis in original). There does not appear to be any attachment to her Statement in the record.

         Dr. Jose Estela completed a Medical Report form concerning Van Allen dated August 26, 2013. That Report, which was co-signed by Nurse Dugan, indicates a “[d]ate first seen” of “9/5/12” and a “[d]ate last seen” of “8/26/13.” (Id. at 96, p. 1110). The primary diagnosis listed in the Report is shoulder arthritis with a secondary diagnosis of back pain. The onset date noted for each condition is “2003.” (Id.). Under the heading “Supportive Test Results” for each diagnosis, the Report states, “MRI 2013.” (Id.). The Report indicated that Van Allen could sit, stand, or walk for less than one hour during an 8-hour workday, only occasionally lift and carry up to five pounds, and could never bend, squat, crawl, climb, or reach.

         B. Mental Impairment/Substance Abuse

         As noted and documented in the ALJ's decision, Van Allen “has a long history of mental health difficulties including multiple inpatient hospitalizations, detoxifications, and visits to hospital emergency rooms for threats to commit suicide while intoxicated.” (Doc. # 10-3, at 13, p. 12). Van Allen's mental health difficulties include diagnoses of depression and bipolar disorder for which he has been prescribed medications. The majority of his interactions with health care providers, however, relate directly to his history of alcohol abuse.

         Van Allen began drinking alcohol at the age of 13 and reported that he drank up to two pints of vodka daily for 20 years. Due to his frequent visits to hospital emergency rooms, he was well-known to hospital staff. Van Allen would sometimes falsely report that he was having seizures during a period of detoxification in order to obtain medication. He also has a history of falsely expressing suicidal thoughts in order to achieve some unrelated purpose, e.g., obtaining temporary food and housing in a hospital. As noted by the ALJ, “[t]he record indicates that the claimant has a history of manipulative behavior and exaggerating his symptoms to obtain favorable treatment or medication.” (Id. at 18, p. 17).

         A Connecticut Valley Hospital admission assessment form dated February 14, 2013, notes that Van Allen reported that his “longest period of sobriety was 6 months when housing was more stable. ‘The tire shop let me have a room.'” (Doc. # 10-11, at 17, p. 1031). During one of Van Allen's hospital admissions for substance abuse rehabilitation, it was noted that he was cooperative with his scheduled groups, collaborated with his assigned staff, and accomplished his goals. Van Allen was incarcerated for periods of time from 2004 to 2007 and from 2008 to 2012. A psychiatric evaluation of him during one of those periods of incarceration, dated December 19, 2011, assesses Van Allen as being alert and awake and having concrete and organized thoughts. A mental status examination of Van Allen made during one of his hospital detoxification admissions to Connecticut Valley Hospital indicates intact memory, concentration, and attention.

         In an evaluation dated September 23, 2011 Dr. Edgardo Lorenzo, a non-examining state agency physician, provided his opinion that “[w]ithout DAA [drug addiction or alcoholism] [Van Allen] is capable of performing simple routine repetitive tasks across a normal work day/week.” (Doc. # 10-4, at 27, p. 106).

         In connection with the hearing before the ALJ, Van Allen's attorney submitted some late-filed exhibits, including a letter from Nicole Goudreau, a social worker at the Wheeler Clinic. The record reflects that Van Allen began treatment at the Wheeler Clinic “on 6/10/13.” (Doc. # 10-11, at 78, p. 1092). The letter from Social Worker Goudreau, dated August 27, 2013, stated in part, “This letter is to clarify the mental health and substance abuse symptoms that Lance Van Allen presents with. His mental health symptoms continue to persist despite cessation of substance abuse, indicating client will continue to struggle to follow through with activities of daily living and other social responsibilities while sober.” (Id. at 84, p. 1098). At the hearing, Van Allen's attorney suggested having “the supervising doctor . . . send a letter as well.” (Doc. # 10-3, at 78, p. 77). The ALJ agreed to a post-hearing ...

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